Tuberculosis is a public health problem of global magnitude. In the U.S. its victims are primarily the poor, foreign immigrants and persons with AIDS. Efforts to control the disease are severely handicapped by the effects of social stigma, and further compounded by issues of race, social class, ethnic stereotypes, immigrant status and HIV co-infection. We will investigate the social dynamics of stigma in relation to TB in two populations particularly affected by all of these issues, Haitians in the U.S. and in Haiti. The study design will enable important comparisons across national settings that highlight the differential effects of political-economic context, as well as comparisons of stigma in a traditional public health clinic and an innovative culturally competent clinic. It will identify differences in stigma dynamics for active disease compared to latent infection, and will measure the impact of stigma on adherence to preventive therapy. Results of the study will enlarge our understanding of the role of social context on stigma enactment, and will help improve illness management strategies. An innovative study design applies the methodology of cultural epidemiology in an interactive quantitative-qualitative approach to developing locally valid measures of illness concepts and behavior. The approach combines the strengths of ethnography with traditional epidemiologic research. We will conduct an ethnography of TB stigma, a cross-cultural epidemiologic study, and a community trial of adherence to preventive therapy. Study sites are Broward County, Florida, and Leogane, Haiti. The methodology has been tested and refined in a broad range of geographic settings and illness problems, including tuberculosis. The research team brings ample qualifications to implement the proposed study, including preliminary studies of stigma and TB among Haitians in South Florida that led to the development of a culturally competent Haitian community clinic. The project has strong support from the Florida Bureau of Tuberculosis Control and Immigrant Health, the Broward County Health Department, Haitian Physicians Abroad and St. Croix Hospital in Haiti. Parallel cultural epidemiologic studies of illness-related stigma are being planned for several other countries. This will provide an opportunity to integrate the Haitian study with a larger, multi-country collaboration. However, this application is designed as a stand-alone project with independent research aims.